Provider Demographics
NPI:1700161247
Name:SEYOUM, GIZACHEW ASEFA
Entity Type:Individual
Prefix:
First Name:GIZACHEW
Middle Name:ASEFA
Last Name:SEYOUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 GERMANTOWN CIR
Mailing Address - Street 2:APT # 919
Mailing Address - City:EAST RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37412-1861
Mailing Address - Country:US
Mailing Address - Phone:615-275-9868
Mailing Address - Fax:
Practice Address - Street 1:856 HIGHWAY 411 N
Practice Address - Street 2:
Practice Address - City:ETOWAH
Practice Address - State:TN
Practice Address - Zip Code:37331-1912
Practice Address - Country:US
Practice Address - Phone:423-263-5656
Practice Address - Fax:423-263-1803
Is Sole Proprietor?:No
Enumeration Date:2011-10-16
Last Update Date:2011-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000035837183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist